Claim Form

• Legal Form Number: 402(a)(2)
• Section: Office of Congressional Workplace Rights (United States)

OCWR ADR Form 1 Page 1 Office of Congressional Workplace Rights Administrative Dispute Resolution (ADR) Claim Form Instructions on how to complete this claim form and how to obtain help are provided at the end of this form Section A: Information about you and the employing office 1. Your full legal name: Last: ___________________ First: ___________________ Middle: ___________________ 2. Preferred mailing address: _____________________________________________________________________ City: ____________________ State: ______________ Zip code: ________________ 3. Preferred phone number: ___________________________ 4. Preferred email: ___________________________________ 5. Legislative branch employing office that this claim is filed against: ___________________________________________________________________________________________ 6. Your employment status: □ applicant □ current employee □ former employee □ unpaid staff 7. If this claim is filed against the Library of Congress, have you filed a formal complaint with the Library’s Office of Equal Employment Opportunity and Diversity Programs concerning the same issues that are raised in this claim form? □ Yes □ No □ My claim is not filed against the Library of Congress If yes, indicate the date that you filed the formal complaint: __________________________________________ 8. Is this claim form intended to replace or amend a claim form that you have already filed with OCWR? □ Yes □ No If yes, include the case name, case number, and date filed: ___________________________________________________________________________________________ Section B: Information about your claim 9. Date(s) or date range that the alleged violation(s) of the Congressional Accountability Act (CAA) occurred. IMPORTANT: Please list the most recent date first. __________________________________________________________________________________________________ 10. Check all that you believe apply to your claim: (a) Unlawful Discrimination: (i) I have been unfairly treated, at least in part, because of my: □ Race or color (ethnicity) □ National origin □ Religion or religious beliefs Office of Congressional Workplace Rights John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov Revised June 2024 OCWR ADR Form 1 (ii) Page 2 □ Sex (could include biological status as a male or female; sexual orientation; and gender or gender identity) □ Pregnancy or pregnancy-related condition (including lactation) □ Age (I am 40 years of age or older) □ Disability or perceived disability □ Genetic information, my family medical history, or my participation in genetic services such as testing □ Uniformed service □ Lie detector test results or my refusal to take a lie detector test Because of what I checked off above, I experienced the following actions: □ My colleagues were treated differently or more favorably than I was. □ □ I was subjected to harassment or a hostile work environment. I was fired, denied a job, or denied a promotion or other employment opportunity. (See “Note concerning claims of disparate treatment discrimination, harassment, or hostile work environments” in the instructions.) □ The employing office’s seemingly neutral policy or practice had a disproportionately negative effect on me and other employees in my protected class. (See “Note concerning claims of disparate impact discrimination” in the instructions.) □ I was denied a reasonable workplace change that would accommodate my: □ □ □ □ (b) Religious beliefs Disability Pregnancy Pregnancy-related condition □ I was asked improper questions about, or I was improperly asked to disclose protected information concerning my genetic information or my participation in genetic services, such as testing. □ Before I received a conditional offer of employment, I was asked improper questions about, or I was improperly asked to disclose protected information concerning my disability or perceived disability. □ Before I received a conditional offer of employment, I was asked improper questions about, or I was improperly asked to disclose protected information concerning my criminal history. (See “Note concerning alleged violations of the Fair Chance to Compete for Jobs Act” in the instructions.) Unlawful Reprisal: I suffered an adverse employment action because I: □ opposed a practice made unlawful by the CAA □ initiated proceedings, made a charge, or testified, assisted, or participated in a hearing or other proceeding under the CAA Office of Congressional Workplace Rights John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov Revised June 2024 OCWR ADR Form 1 (c)...